1. Self-Report Nutrition & Body Image Questionnaire
Food Habits & Behaviors
For each question, circle the answer and respond to the questions that best describe your behavior
1. How many days each week do you eat breakfast? None 1-2 days 3-5 days 6-7 days
2. How many days each week do you eat lunch? None 1-2 Days 3-5 days 6-7 days
3. How many days each week do you eat dinner? None 1-2 days 3-5 days 6-7 days
4. How often do you eat between meals after dinner?
Daily Several times a week Once a week or less Rarely Never
5. Do you limit any food or food groups (such as meat, fruit, grains, vegetables, or dairy)? Yes No
if yes, explain:
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6. How often do you eat any of these foods?
a. Candy, chocolate, chips, cookies
Daily Several times a week Once a week or less Rarely Never
b. Donuts, muffins, biscuits, cake, sweet bread
Daily Several times a week Once a week or less Rarely Never
c. Ice cream, frozen yogurt
Daily Several times a week Once a week or less Rarely Never
d. Sour cream, mayonnaise
Daily Several times a week Once a week or less Rarely Never
7. How often do you drink any sweetenedbeverages or energy drinks (e.g. regular soda, fruit drinks, sweetened
tea, coffee, Kool-Aid® punch, or sports drinks)?
Daily Several times a week Once a week or less Rarely Never
8. How much water do you drink each day?
<1 cup 1-2 cups 3-5 cups >5 cups
9. How many times per week do you eat or take out a meal from a fast food restaurant (such as McDonalds’s,
Wendy’s, Chic Fil’ A, Burger King, etc.)?
Daily Several times a week Once a week or less Rarely Never

2. 10. Are you a vegan (Excludes all animal products and animal meat, including eggs, dairy, beeswax, and honey)?
Yes No
11. Are you a vegetarian (Excludes animal meat such as: pork, beef, chicken, or fish)?
Yes No
12. How often do you currently take a multivitamin or folic acid supplement in a week?
1-2 days 3-5 days 6-7 days Never
If yes, which brand(s) or type(s) and are they prescribed by your doctor?
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13. Do you currently take any vitamins or mineral supplements such as iron or calcium?
Daily Weekly Rarely Never
If yes, which brand(s) or type(s) and are they prescribed by your doctor?
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14. Do you currently use herbal supplements such as chamomile or ginseng?
Daily Weekly Rarely Never
If yes, which brand(s) or type(s) and are they prescribed by your doctor?
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15. Do you currently use any pills or teas to lose weight?
Daily Weekly Rarely Never
If yes, which brand(s) or type(s) and are they prescribed by your doctor?
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16. Do you use protein powders, creatine, or other supplements that claim to increase muscle mass?
Daily Weekly Rarely Never
If yes, which one(s) and are they prescribed by your doctor?
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17. Are you on a special diet that has been prescribed to you by your doctor? Yes No
If yes, what is the diet?
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18. If you do have a medically prescribed diet, about how closely do you follow it?
Daily Several times a week Once a week or less Rarely Never
19. Has your doctor evertold you that you have anemia or another nutrition-related health issue?
Yes No
if yes, explain:
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Questions 20 through 23 are specificallyfor females.
20. Have you begun your menstrual cycle? Yes No
21. If yes, has it stopped for more than one month at a time not due to pregnancy? Yes No
22. Are you pregnant? Yes No Unsure
23. If you are pregnant, do you ever eat any of the following? Circle Below
a. Raw or uncooked eggs, meat, shellfish, including sushi
b. Deli or lunch meat (such as bologna) or hot dogs without heating or steaming
c. Raw milk (unpasteurized), cheese or juice including soft cheeses such as feta, blue cheese queso de
crema, asadero, queso fresco, queso panela, or any homemade cheeses
d. Alfalfa sprouts, mung beans, or other sprouts
e. Shark, swordfish, king mackerel, or tilefish
f. Albacore tuna more than 6 ounces/week
B. Do you currently eat fish or shellfish (such as lobster, tuna, albacore, crab, muscles, oysters, shrimp, or
sushi, etc.) more than twice a week?
Yes No if yes, explain:
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4. C. Do you currently eat fish caught locally by self, friends, or family more than once a week (Such as local
carp, bass, etc.)?
Yes No if yes, explain:
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D. Have you fasted during this pregnancy or do you plan to fast?
Yes No if yes, explain:
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Body Image, Eating Patterns & Weight Management
For each question, circle the answer and respond to the questions that best describe your behavior
1. Do you worry about gaining weight? Yes No
2. Are you concerned with losing weight? Yes No
3. Are you on a diet? Yes No
4. Do you limit your food intake to lose weight? Yes No
5. Do you fast for religious purposes? Yes No
6. Do you fast for weight control purposes? Yes No
7. Does your mood depend on your weight? (e.g., if you gain one pound you become depressed, irritable,
angry, sad, etc.)? Yes No
8. Do you feel bad about yourself if you gain weight? Yes No
9. If you gain one pound, do you worry that you will continue to gain weight? Yes No
10. Do you think of certain foods as being either “good” or “bad”? Yes No
11. Do you ever feel guilty about eating “bad “foods? Yes No
12. Do you use foods to comfort yourself? Yes No
13. Do you ever feel out of control when eating? Yes No
14. Do you spend a significant amount of time thinking about food and when you will eat? Yes No
15. Do you vomit or have thought about vomiting as a way to control your weight? Yes No

5. 16. Do you try to hide how much you eat? Yes No
17. Do you use laxatives, water pills, excessive exercise etc., to prevent weight gain? Yes No
18. Are you dissatisfied with your body size or shape? Yes No
19. Do you eat until you feel stuffed? Yes No
Physical Activity
For each question, circle the answer and respond to the questions that best describe your behavior.
If you are not pregnant:
1. On how many of the past sevendays did you participate in moderate physical activity (for example, walking
or riding a bike) for at least 30 minutes?
None 1-2 days 3-5 days 6-7 days
2. If yes, how long did you spend exercising per day?
1-15 minutes 16-30 minutes 31-45 minutes 46-60 minutes 1 hour or more
3. On how many of the past sevendays did you participate in vigorous physical activity (for example,
basketball fast dancing, or swimming) for at least 30 minutes?
None 1-2 days 3-5 days 6-7 days
4. If yes, how long did you spend exercising per day?
1-15 minutes 16-30 minutes 31-45 minutes 46-60 minutes 1 hour or more
5. How many hours per day do you spend watching TV, playing video games, or other electronic screen
time on your down time (phone, movies, etc.)?
None 1-2 hours per day 3-5 hours per day 6-7+ hours per day
6. Outside of school and work, how many hours do you spend per day watching television, going online, or
playing computer games?
None 1-2 hours per day 3-5 hours per day 6-7+ hours per day
If you are pregnant:
7. On how many of the past sevendays did you participate in moderate physical activity (for example, walking
or riding a bike) for at least 30 minutes?
None 1-2 days 3-5 days 6-7 days
8. If yes, how long did you spend exercising per day?
1-15 minutes 16-30 minutes 31-45 minutes 46-60 minutes 1 hour or more
9. On how many of the past sevendays did you participate in vigorous physical activity (for example,
basketball, fast dancing, or swimming) for at least 30 minutes?
None 1-2 days 3-5 days 6-7 days

6. 10. If yes, how long did you spend exercising per day?
1-15 minutes 16-30 minutes 31-45 minutes 46-60 minutes 1 hour or more
11. How many hours per day do you spend watching TV, playing video games, or other electronic screen
time on your down time (cell-phone, movies, etc.)?
None 1-2 hours per day 3-5 hours per day 6-7+ hours per day
12. Outside of school and work, how many hours do you spend per day watching television, going online, or
playing computer games?
None 1-2 hours per day 3-5 hours per day 6-7+ hours per day
Client Awareness & Readiness for Change
For each question, circle the answer and respond to the questions that best describe your behavior
1. How would you rate your eating behaviors?
I need to eat more I need to eat less My eating behaviors are ok
2. Are you interested in changing your eating habits? Yes No
3. Are you thinking about changing your eating habits? Yes No
4. Are you ready to change your eating habits? Yes No
5. Are you in the process of changing your eating habits? Yes No
6. Are you trying to maintain changes in your eating habits? Yes No
7. What eating or body changes would you like to modify?
a. ________________________________________
b. ________________________________________
c. ________________________________________
d. ________________________________________
8. What eating or body changes would you like to maintain?
a. _________________________________________
b. _________________________________________
c. _________________________________________
d. _________________________________________
9. What do you need to help you make or maintain your desired changes?
Information Assistance Other: explain
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